Asbury Park Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to administer insulin (a medication used to lower blood sugar) according to the sliding scale in a timely manner (a set of instructions for administering insulin dosages based on specific blood glucose readings) when the insulin was administered more than 2 hours after the blood glucose reading for one of nine residents observed during the medication pass (Resident 157). This failure created the potential for inaccurate dosing and adverse effects from uncontrolled blood sugar.Findings: During a medication observation on 3/23/26 at 10:06 a.m. at the 1 A medication cart, Licensed Nurse (LN 4) was observed preparing 10 medications, for Resident 157, which included Regular Insulin (short acting insulin). At 10:15 a.m., LN 4 was observed administering the Regular Insulin to Resident 157's left lower abdomen. A review of Resident 157's physician order indicated the following order for Regular Insulin 100 unit/milliliter (concentration) to be given as per sliding scale, dated 3/21/26: Finger Stick Glucose (FSG, a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one out of 30 sampled residents (Resident 160) received care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 160's suprapubic catheter (a tube that drains urine from the bladder through a small incision in the lower abdomen) bag was left on the floor.This failure had the potential for Resident 160 to develop infection and possible urinary catheter complications.Findings:A review of Resident 160's clinical record indicated Resident 160 was admitted March of 2026 and had diagnoses that included malnutrition (state of poor nutrition that occurs when the body does not receive enough or the right nutrients to function properly), benign prostatic hyperplasia (BPH- the prostate gland grows larger than normal potentially causing urinary problems), and obstructive and reflux uropathy (occurs when the urine cannot drain through the urinary tract).A review of Resident 160's Minimum Data Set (MDS- a federally mandated resident assessment tool)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for a census of 134 residents, when flies were observed in the residents' rooms.This failure decreased the facility's potential to maintain a pest free environment for the residents.Findings:A review of Resident 1's admission Record, dated 8/14/25, indicated Resident 1 was admitted to the facility in 2025.A review of Resident 2's admission Record, dated 8/14/25, indicated Resident 2 was admitted to the facility in 2021.During a concurrent observation and interview on 8/14/25 at 9:46 a.m. with Resident 1, Resident 1's room was observed. Resident 1 confirmed and stated there were flies in the room all the time. During a concurrent observation and interview on 8/14/25 at 9 a.m. with Resident 2, Resident 2's room was observed. The sliding door was opened and had no screen. Resident 2 confirmed and stated there were flies flying around the room.During an interview on 8/14/25 at 9:48 a.m. with Certified Nursing Assistance (CNA), CNA confirmed the sliding door in Resident 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure dignity was promoted for one of three sampled residents (Resident 1), when the resident was left with a soiled brief for an extended period of time. This failure had the potential to result in Resident 1 not attaining his highest practicable social, physical, mental and psychosocial well-being. Findings: Resident 1 was admitted to facility summer 2016 with diagnosis of Muscle Atrophy and Wasting (weakening, shrinking, and loss of muscle). During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 2/11/25, the MDS indicated Resident 1 had incontinence. During a review of Resident 1's Care Plan Report , dated 1/25, the care plan indicated, The resident is total dependent on 1 staff for toileting. During a concurrent observation and interview on 3/20/25 at 10:40 a.m. with Infection Preventionist (IP) outside Resident 1's room, the IP confirmed there was a strong odor coming from Resident 1's room. During an observation on 3/20/25 at 10:43 a.m. in Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to protect 3 of 6 sampled residents (Resident 2, Resident 4, and Resident 6) from abuse by peer residents for a census of 136 when; 1. Resident 1 slapped Resident 2 in the face; 2. Resident 3 punched Resident 4 in the Thigh; and, 3. Resident 3 expressed verbal slurs to Resident 6. This failure resulted in 3 sampled residents being abused by peer residents and had the potential to cause physical injury and negatively impact their psychosocial well-being. Findings: 1. A review of Resident 1's admission record , indicated Resident 1 was admitted in January 2025 with multiple diagnoses including Major depressive disorder (a disorder that causes persistent feelings of sadness and loss of interest) and Schizophrenia (a chronic mental condition that affects how a person thinks, feels, and behaves). A review of Resident 1's Minimum Data Set (MDS-Federally mandated assessment tool), Cognitive Patterns, dated 1/15/2025, indicated Resident 1 had a Brief Interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the planned menu or spreadsheet (a menu excel sheet that indicated what items and portions to be served for each prescribed diet) was followed for the therapeutic diets during the lunch meal distribution on 1/8/25 when: 1. 20 residents (Resident 16, 17,18, 26, 28, 41, 44, 47, 60, 62, 64, 71, 80, 82, 92, 98, 100, 101, 110, and 386) with CCHO (control carbohydrate) diets (diet uses for person with diabetes and maintain a stable sugar level throughout the day) with regular portion received margarine instead they should not receive margarine, 2. Two Residents (Resident 34 and 37) with CCHO, Renal (refer to the kidney) diet (diet that manage a person with diabetes and kidney disease) did not receive baked fish and/or wheat roll but they should have as indicated on the spreadsheet, 3. Nine Residents (Resident 15, 21, 25, 56, 74, 95, 96, 106, and 109) with puree diet (diet with texture that is soft and smooth and prepares in a food processor or blender for people who have difficulty chewing and/or swallowing)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food safety when: 1. The ice machine was not clean, 2. Various sizes kitchenware in the clean and ready-to-use storage areas: a. Were stacked and stored wet b. Had food particles 3. An air gap was not found on the food production sink, 4. Dietary Aide (DA) 1 did not verbalize the process of manual dishwashing correctly, 5. [NAME] (CK) 1 and CK 2 had beard and did not have beard restraint. These failures had the potential to result in food contamination which could cause illness in 128 out of 128 medically vulnerable residents who received and consumed food from the facility kitchen. Findings: 1. A concurrent observation and interview on 1/7/25 at 10:03 a.m. with Dietary Assistant Manager (DAM) and Director of Environmental Services (DES) regarding the ice machine was conducted. DAM stated the maintenance department was responsible for monthly cleaning and sanitizing for ice storage bin and the outside vendor was responsible for the deep cleaning (cleaning and sanitizing the machinery parts on the top…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors when one of two garbage dumpsters, located outside the facility, was not closed securely with the dumpster lids. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread diseases in the facility. Findings: During an observation and concurrent interview on 1/7/25 at 8:58 a.m. with Dietary Assistant Manager (DAM), observed one out of two outside garbage bins was covered with lids but not securely completely covered. The lids lacked integrity to securely cover the bin and left gaps on both sides. DAM confirmed and agreed the lids could not securely cover the bin. She stated it was not acceptable. During an interview with Registered Dietitian (RD) on 1/9/25 at 1:45 p.m., RD stated the dumpster garbage bins should be covered tightly with the lids. She added the bins should cover without any opening or gaps to prevent issues from the pests and rodents. A review of facility policy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure: 1. Accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for three out of four residents (Residents 58, 65, and 69) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Medication accountability when two out of four medication carts' controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were missing signatures of the outgoing and incoming nursing shift; 3. An efficient system was in place to accurately document and secure emergency medications (E-Kit) for a census of 132. 4. Medications were secured safely when multiple bottles…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure three of 31 sampled residents (Resident 7, Resident 128, and Resident 25) were free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior) when: 1. Resident 7 received Seroquel (an antipsychotic to treat mental illness) without implementation of non-pharmacological (non-drug) interventions in an effort to lower the dose or discontinue the medication; and 2. Resident 128 received Seroquel without an adequate indication for its use. 3. Resident 25's behavior order was different from the behavior being monitored for the use of Lorazepam (anti-anxiety medication) and there was no documented evidence of non pharmacological interventions used when behavior occurred. These failures had the potential to result in unnecessary use of medication. Findings: 1. A review of Resident 7's medical record indicated Resident 7 was admitted to the facility on [DATE] with diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medication error rate was not 5% or greater when the error rate was 12.5% based on four medication errors out of 32 opportunities observed during a medication pass for three of five residents (Resident 12, 104, and 110). These failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and potential to affect the resident's clinical conditions. Findings: 1. During a medication pass observation on 1/7/25 at 8:42 a.m. with Licensed Nurse 2 (LN 2), LN 2 was observed preparing 11 medications, including diclofenac gel (used to relieve joint pain) 4 grams (g, a unit of measurement) for Resident 110. LN 2 used a dosing card to measure topical medication. LN 2 measured 2 g. A review of Resident 110's medical record indicated a physician's order dated 12/30/24, for diclofenac gel apply 4 g topically (applied to the skin) three times a day to affected joints for arthritic pain (swelling and tenderness of one or more joints). During a concurrent interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure: -Medications were stored in accordance with manufacturer specifications; -Opened medications were dated with an open and discard date, to ensure they were not used beyond the discard date; -Expired and discontinued medications were disposed of in accordance with facility policy and procedure (P&P); -Medication carts were kept clean and orderly and single resident multidose medications were appropriately labeled with resident specific labels to ensure they were used for the right resident; -Controlled medications (those with high potential for abuse or addiction) were stored in accordance with facility P&P; and -Medication carts were kept securely locked when left unattended. - Resident 81's inhaler was observed at the resident's bedside. The deficient practices had the potential for residents to receive medications with unsafe or reduced potency from being used past their discard date or improper storage, incorrect medication, and diversion or misuse of medications from not being securely stored in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure services furnished by outside resources had written agreements when three out of 31 sampled residents' (Resident 15, Resident 36, and Resident 51) dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) services were provided without existing agreements with dialysis clinics. This failure had the potential to result in the lack of responsibility and accountability in the dialysis services received by Resident 15, Resident 36, and Resident 51. Findings: 1a. During a review of Resident 36's admission record, the record indicated Resident 36 was admitted in October 2024 with diagnoses that included end-stage renal disease (ESRD, irreversible kidney failure) and dependence on renal dialysis. Resident 36's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 36 had intact cognition. During a review of Resident 36's care plan, initiated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 132 when: 1. Resident 36's nasal cannula (a medical device with two prongs that is connected to an oxygen source used to deliver supplemental oxygen directly into the nostrils) was observed on the floor when not in use; 2. Resident 46's nasal cannula was observed on the floor when not in use; 3. Dust particles were observed on the vents above the clean linen area and dust particles and moisture were observed at the back of the washers in the laundry room; 4. Resident 71's nebulizer (machine that transforms liquid medication into an inhalable mist that allows it to reach the lungs directly) tubing and mask was not stored properly, not labeled with date changed, and oxygen concentrator (machine that converts surrounding air into oxygen) humidifier bottle (used to humidify supplemental oxygen) was not labeled with date changed; and, 5. Resident 3's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the building and equipment were maintained in a functional and operable manner when pipes in the laundry room were dirty, corroded, and leaking. This failure had the potential to result in the facility not providing safe and sanitary handling of laundry items used by residents for a census of 132. Findings: During a concurrent observation and interview on 1/9/25 at 11:49 a.m. with Laundry Staff (LS) and the Director of Environmental Services (DES) in the laundry room, the floor at the back of the washer was observed wet, pipes were observed with dust particles, one pipe was observed corroded and with greenish color. LS and the DES confirmed the observation. The DES stated the leakage was coming from the corroded pipe and stated, We called the company but no confirmation on when will be repaired, we think the company have to replace the pipe, there should not be leakage. During a concurrent observation and interview on 1/9/25 at 11:56 a.m. with the Infection Preventionist (IP), the IP confirmed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure informed consents were obtained from authorized resident representative for one of 31 sampled residents (Resident 97) when Resident 97's consent to treat, Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life), and psychotropic medication (drugs that affect brain activities associated with mental processes and behaviors) consents were not signed by Resident 97's Responsible Party (RP). This failure increased the potential for Resident 97's RP to not be informed of the risks and benefits of treatment and medication. Findings: During a review of Resident 97's admission records, the records indicated Resident 97 was admitted in January 2024 with diagnoses that included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and dementia (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to protect and keep secure, when not in use, confidential resident health data and records for a census of 132. This failure had the potential to expose and disclose personal and confidential health information to unauthorized individuals. Findings: During an observation on 1/7/25 at 4:30 p.m. in hallway 2A. Medication Cart 2A's computer was observed unattended and with a resident profile open in-between resident rooms facing out towards the resident hallway. During an interview on 1/7/25 at approximately 4:31 p.m. with Licensed Nurse 7 (LN 7), LN 7 stated he was aware the computer was left unlocked and unattended with resident records accessible. He stated resident records should never be left open and accessible to unauthorized individuals and that doing so would be a violation of their confidentiality. During an interview on 1/8/25 at 10:58 a.m. with the Director of Nursing (DON), the DON stated that it was her expectation that nursing staff ensured resident records were not visible to any unauthorized staff.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide written notice of bed hold for one of 31 sampled residents (Resident 15) when Resident 15 was transferred to the hospital and Resident 15's Responsible Party (RP) was not provided written notice of bed hold for return to the facility. This failure had the potential for Resident 15's RP to not be informed of Resident 15's right to return to the facility. Findings: A review of Resident 15's admission Record indicated Resident 15 was initially admitted to the facility in August 2022 with multiple diagnoses including end stage renal disease (loss of kidney function, kidneys cannot remove waste from the body) with dependence on dialysis (treatment that removes waste and excess fluid from the body), chronic respiratory failure (lungs cannot get enough oxygen into the blood or eliminate carbon dioxide), and heart failure (heart does not pump blood as well as it should). The admission Record indicated Resident 15 was readmitted to the facility in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow professional standards of quality as stipulated by their admission policy and procedure to ensure accuracy of admission medications for one of 31 sampled residents (Resident 487) when a psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication order was not carried over upon admission. This failure resulted in Resident 487 not receiving psychotropic medication for eight days and increased the potential for Resident 487 to experience emotional distress. Findings: A review of Resident 487's admission record, indicated Resident 487 was admitted [DATE] with multiple diagnoses including aftercare following joint replacement surgery. A review of Resident 487's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 1/3/25, indicated Resident 487 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 15 out of 15 indicating the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 51) received necessary foot care when toenails were long and thick. This failure increased the potential for Resident 51 to experience pain and infection. Findings: A review of the admission Record indicated Resident 51 was initially admitted [DATE] with diagnoses including type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic chronic kidney disease (high blood sugar levels damage the kidney's ability to function). A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) indicated Resident 51 was cognitively intact with a score of 15 out of 15. A review of Resident 51's physician order dated 12/16/24 indicated, May receive podiatry care [the foot doctor examines the foot and ankle to correct problems identified] Q…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure an ongoing communication and collaboration for the development and implementation of the dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care plan by the facility and dialysis staff for one of 31 sampled residents (Resident 36), when Resident 36' s anemia (a condition where the body does not have enough healthy red blood cells) medication was not communicated with the dialysis clinic and was signed as given at dialysis. This failure resulted in the facility not being aware of Resident 36's current anemia management and decreased the facility's potential to monitor Resident 36 for the medication's effectiveness and side effects. Findings: During a review of Resident 36's admission record, the record indicated Resident 36 was admitted in October 2024 with diagnoses that included end-stage renal disease (ESRD, irreversible kidney failure), dependence on renal dialysis, and anemia. Resident 36's Minimum Data Set (MDS, a federally…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the consultant pharmacist (CP) identified and reported to the facility irregularities related to the medication regimen for one of 31 sampled residents (Resident 128) during the Medication Regimen Review (MRR). This failure resulted in inadequate monitoring and had the potential for medications not being optimized for best possible health outcome. Findings: A review of Resident 128's medical record indicated Resident 128 was admitted to the facility in 12/9/24 with diagnoses including Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), schizophrenia unspecified (a mental illness that is characterized by disturbances in thought) and diabetes (a chronic disease that affects how the body uses sugar for energy). A review of Resident 128's medical record indicated the following physician's order for Seroquel (an antipsychotic medication to treat mental illness): -Seroquel 25 mg (milligrams, a unit of measurement): give 1 tablet by mouth one time a day for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to accommodate the special dietary requirement for two residents (Resident 106 and 108) during the lunch observation on 1/7/25. This deficient practice had the potential to result in meal dissatisfaction and decreasing meal intake that may lead to further compromising medical and nutrition status and/or weight loss of residents. Findings: A review of the admission Record for Resident 106 indicated Resident 106 had other diagnoses including dysphagia (difficulty swallowing). During a dining observation on 1/7/25 at 12:18 p.m., Resident 106's meal ticket (a ticket including resident's diet, date, allergies, specific food and beverage items, dislikes, and likes) indicated Puree (food has been ground to a soft, smooth consistency) with nectar thick liquids (like heavy syrup consistency) and Resident 106's dislikes included broccoli. During a concurrent observation and interview on 1/7/25 at 12:27 p.m., Certified Nursing Assistant (CNA) 1 stated the puree green vegetable in Resident 106's plate was broccoli. During…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failure to ensure a call light (a device used by a resident to signal the need for help) were accessible for 2 of 31 sampled residents (Resident 22 and Resident 82), when Resident 22 and Resident 82 were not physically able to use the call light provided when it was out of reach. These failures had the potential to result in unmet resident needs and delayed staff response. Findings: 1a. A review of Resident 22's admission record, indicated Resident 22 was admitted with multiple diagnoses including generalized muscle weakness. A review of Resident 22's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 12/17/24, indicated Resident 22 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 11 out of 15 indicated moderate cognitive impairment and resident 22's mobility was for Substantial/maximal assistance (staff does more than half of the effort for any mobility needs). During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to identify that one of three sampled residents (Resident 1) left facility without staff awareness or physician order for Leave of Absence (LOA), when Resident 1 left facility with unidentified person and was not known to have left facility until he returned to the facility on his own. This failure resulted in Resident 1 going to an unsafe environment with risk for harm and injury. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in June 2024 with multiple diagnoses including acute osteomyelitis (infection in a bone) of left ankle and foot, pressure injury to right hip, and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS- an assessment tool), Cognitive Patterns, dated 6/20/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition) score of 14 out of 15 which indicated Resident 1 was cognitively intact. A review of Resident 1's MDS, Functional Abilities and Goals, dated 6/20/24, indicated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to follow and maintain an effective Infection Prevention and Control Program (IPCP) for a census of 134 residents when: 1. A facility staff did not wear required personal protective equipment (PPE) while providing catheter care for Resident 1, who was on Enhanced Standard Precautions (ESP- also known as Enhanced Barrier Precaution/EBP). 2. Resident 1, Resident 2, and Resident 3, who were on ESP, did not have required PPE readily available outside the room. These failures resulted in increased risk for cross-contamination (transfer of bacteria from one person, object, or place to another) and may cause infections among residents. Findings: A review of an admission record indicated Resident 1 was admitted to the facility early 2024 with multiple diagnosis which included benign prostatic hyperplasia (BPH – enlarged prostate that can cause urinary difficulty) and Parkinson ' s Disease (a disorder of the central nervous system that affects…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to promote individual care and dignity, when the staff failed to respond to three of five sampled residents (Resident 1, Resident 2, and Resident 5), who needed assistance with personal care and the staff did not answer their call lights in a timely manner. This failure resulted in the residents' needs not being met, they experienced discomfort, embarrassment, and felt helpless. Findings: During a phone interview with Resident 1's family member (FM) on 8/1/24 at 10:20 a.m., FM stated that his father did not receive proper staff assistance with personal care while residing in the facility. The FM stated his father had to wait for an hour or longer to have his call light answered which caused him to feel anxious and frustrated. The FM stated that his father could maintain his bladder and bowel control and make his needs known, but by the time staff responded to his calls, he had already wet or soiled himself because he could not hold it any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to report the result of the 5-day investigation within the required timeframe for two residents (Resident 1 and Resident 2) when Resident 1 scratched Resident 2. This failure decreased the facility's potential to provide appropriate corrective actions to safeguard the health and safety of the residents. Findings: A review of Resident 1's progress note, dated 5/31/24 at 10:09 a.m. indicated, At [9:15 a.m.] .[Resident 1] had gotten into an altercation with her room mate [sic] .[Resident 2] approached [Resident 1] exclaiming 'get out of here! Get out of here!' [Resident 2] then swiped her hand towards [Resident 1]. In response [Resident 1] grabbed [Resident 2]'s hand and swiped her own hand towards [Resident 2]'s chest, making contact with her skin and leaving a wound of 3 prominent scratch marks on her chest . The facility was unable to provide the California Department of Public Health (CDPH) with documented evidence the facility submitted a summary of the investigation within 5 working days of the incident and the appropriate…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and documentation review, the facility failed to ensure a safe environment for the residents, staff, and the public when the evacuation routes were cluttered with carts, bedside commode, linen bins, and garbage bins in a 139-bed facility. This failure caused Resident 4 to feel unsafe in the facility and increased the potential for a delay in an evacuation should an emergent situation arise that would have the facility use this evacuation route. Findings: Review of Resident 4's clinical record, admission Record , indicated the resident was admitted to the facility for aftercare of back surgery. In an observation and concurrent interview on 5/23/24 starting at 3:23 p.m. in Resident 4's room, the resident stated that he had concerns regarding the resident safety in the building. Resident 4 stated, I want to show you something and got out of his bed and took the lead in his wheelchair to one of the emergency exit doors. It was a double exit door with a sign on the window of the door, EMERGENCY EXIT ONLY. NO RESIDENT IS ALLOWED THIS WAY. Below it, another…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to meet professional standards of care when the physician order for one of three sampled residents (Resident 1) was not implemented according to the facility's policy and procedures. This failure resulted in Resident 1 to have received a thickened liquid diet despite the physician order and/or the resident's preference. Findings: Review of Resident 1's admission Record, the record indicated the resident was a long-term resident in the facility since 2011 with diagnoses that included difficulty swallowing after a stroke. During an observation and interview on 3/18/24 at 10:31 a.m., Resident 1 was observed lying in bed and stated the facility kept bringing her thickened liquids that she didn't like. The resident stated her sister brought her chicken, soda, [Brand Name] hamburgers but she did not, choke a bit. The resident stated, I know what I can eat, and indicated staff did not believe that she no longer needed thickened liquids. Resident 1 stated she spoke to her doctor a few weeks ago about her improvement…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had access to water. This failure resulted in Resident 1 to be thirsty and increased the potential for dehydration, urinary tract infection, pneumonia, skin infections, confusion and disorientation. Findings: Review of Resident 1's admission Record indicated the resident was a long-term resident in the facility with diagnoses that included stroke, lung disease, and heart problems. During a concurrent observation and interview on 3/18/24 starting at 10:31 a.m., in Resident 1's room, Resident 1 was observed lying in her bed and reported that she had skin issues. The resident uncovered the blanket and exposed her right leg that was wrapped in a white dressing from below her knee down to the ankle. The resident indicated she had frail skin. The resident then moaned, I am so thirsty and they don't give me water. The resident's mouth had stringy saliva and her lips partially peeled which appeared to be dry. There was a about 10-ounce size sippy cup (a spouted cup)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure respiratory infection control practices were promoted for one of three sampled residents (Resident 1) when the resident's nasal cannula (a plastic tubing that supplies oxygen to the resident through their nostrils) was found on the floor and the tubing was dated 1/18/24. These failures place Resident 1 at increased risk for respiratory infections who had already compromised lung capacity. Findings: Review of Resident 1's admission Record indicated the resident was a long-term resident in the facility with diagnoses that included lung disease and personal history of other infectious and parasitic diseases. During an observation on 3/18/24 at 10:31 a.m., Resident 1 was observed lying in her bed with her eyes open. Next to her bed, there was an oxygen (O2) concentrator in operation and the nasal cannula connected to the concentrator was found on the floor. There was also crumbled white tissue paper next to the nasal cannula on the floor. The nasal cannula was dated 1/18/24. The oxygen concentrator was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy and procedure review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect, when Resident 1 complained that a staff member cut her hair against her wishes. This failure caused Resident 1 to feel upset and distressed. Findings: Resident 1 was admitted to the facility initial admission in early January 2022 and readmission in March 2022, with diagnoses including muscle weakness, pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region stage 4 (the portion of spine between lower back and tailbone, Stage 4 extends to muscle, tendon, or bone), and Rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet). Resident 1's latest Minimum Data Set (MDS, an assessment and care planning tool), dated 11/3/23, indicated resident scored 13 out of 15 on a Brief Interview for Mental Status, where score of 13 -15 indicated intact cognitive status. In an interview with Resident 1 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to meet professional standards of quality for one of 3 sampled residents (Resident 7) when nursing staff did not follow the physician's order for foley catheter (a tube inserted through the urethra to drain urine from the bladder) care. This failure resulted in Resident 7 having multiple urinary tract infections (UTIs) within two months of admission to the facility and was sent to the acute care hospital (ACH) with severe sepsis and acute organ dysfunction (the body's extreme reaction to infection). Findings: A review of Resident 7's 'admission Record,' indicated Resident 7 was admitted to the facility from the ACH on 12/6/23 with diagnoses including Benign Prostatic Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract infection and urine retention. A review of Resident 7's latest Minimum Data Set (MDS, an assessment and care planning tool), dated 12/3/23, indicated Resident 7 scored 12 out of 15 on a Brief Interview for Mental Status (BIMS, tests cognition)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to intervene in a timely manner to prevent an abrupt weight loss for one of 3 sampled residents (Resident 1) when she had a pattern of meal refusals and lost 14.9 pounds (lb) in one month. This failure resulted in Resident 1 having an unplanned weight loss (14.9 lbs ) in one month and had the risk potential to have caused the resident's inability to fight infections. Findings: A review of the admission Record indicated Resident 1 was admitted to the facility in early January 2022 with diagnoses including muscle weakness, pressure ulcer of sacrum (the portion of spine between lower back and tailbone region) stage 4 (the ulcer presents as full thickness tissue loss with exposed bone, tendon or muscle), dysphagia (difficulty swallowing ), Endocarditis (inflammation of the inside lining of the heart due to bacterial infection), Rheumatoid arthritis (a chronic inflammatory disorder usually affecting small joints in the hands and feet) and a recent hospitalization due to Pneumonia and COVID-19. A review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure proper infection prevention and control practices were maintained during a Covid-19 (respiratory disease caused by a virus and spread from person to person) outbreak when four staff did not properly don (put on) PPE (personal protective equipment- mask/N95 respirator). This failure had the potential to result in the spread of infections among residents and staff. Findings: During an observation and interview on 2/6/23 at 12:55 p.m., a Certified Nurse's Assistant (CNA 1) was observed wearing an N95 (type of mask) mask with the top strings under the ear and the bottom string of the mask hanging under the face. When the CNA 1 was asked to explain the correct way to wear her mask, CNA 1 stated she wore it like that as she could not breathe. CNA 1 further stated that it was important to wear the mask correctly to protect herself and the residents from getting sick. During an observation and interview on 2/6/23 at 2:20 p.m., Licensed Nurse (LN 2) was observed wearing N95 mask on his chin and stated that he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, facility document review, and facility policy review, the facility failed to timely address a resident concern of missing prescription glasses for 1 (Resident #94) of 26 sampled residents. Findings included: Review of a facility policy titled, Grievances/Complaints, Filing, revised in April 2017, revealed, 6. When applicable, upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report if applicable of such findings to the administrator. Review of a facility policy titled, Lost and Found, revised in January 2008, revealed, 5. Resident or family complaints of missing items must be reported to the director of nursing services. The policy revealed, 7. Reports of misappropriation or mistreatment of resident property are immediately investigated. A review of Resident #94's admission Record indicated the facility admitted the resident on 09/13/2023, with diagnoses of orthopedic aftercare following surgical amputation and type 2 diabetes. A review of Resident #94's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and policy review, the facility failed to ensure 1 (Resident #470) of 4 sampled residents reviewed for food was not provided dairy products. Findings included: Review of a facility policy titled, Food Preferences, dated 2023, revealed, POLICY: Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group. Further review of the policy indicated, PROCEDURE: Food preferences will be obtained as soon as possible though the initial resident screen. Review of a facility policy titled, Food Allergies, dated 2023, revealed, POLICY: Residents with food allergies will be identified upon admission. Further review of the policy indicated, 5. Allergies will be noted on the tray card, the resident diet profile, and posted in the kitchen and nursing station, if necessary. A review of Resident #470's admission Record revealed the facility admitted the resident on 12/05/2023, with diagnoses that included left femur fracture, muscle weakness, and asthma. A review of Resident #470's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to adhere to professional standards of practice for one of 3 sampled residents (Resident 1) when baclofen (drug used for muscle spasms) was ordered for him without consideration of his kidney failure. This failure had the potential risk to result in drug toxicity. Findings: According to Resident 1's 'admission Record' the facility admitted him recently with multiple diagnoses which included End Stage Renal Disease (ESRD, kidneys no longer work properly) and was dependent on hemodialysis (a life sustaining procedure were a machine does some of the work of the kidneys by filtering harmful waste, salts, and fluids from the blood), diabetes and right below knee amputation. Resident 1 scored 14 out of 15 in a Brief Interview for Mental Status (BIMS, test memory and recall) contained in his Minimum Data Set (MDS, an assessment tool) which indicated he was cognitively intact. A review of the Resident 1's physician orders concurrently with the Nurse Practitioner (NP) on 9/27/23, at 2:05 p.m., the NP validated another NP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide services to maintain grooming and personal hygiene for one of three residents (Resident 1), when Resident 1 did not receive a shower during her stay at the facility, for a census of 132. This failure resulted to Resident 1 developing a hair knot. Findings: A review of the clinical record indicated Resident 1 was admitted with diagnoses including a displaced intertrochanteric fracture of right femur (a type of break in the hip and bone moved out of position) and pathologic fracture (a break caused by underlying disease) of the right ankle. Further review of Resident 1's clinical record indicated the following: - Resident 1 had 35 days of facility stay. She stayed 17 days on the initial admission from 6/14-7/2/23 and 18 days on readmission from 7/9-7/27/23. Resident was in the acute care hospital from 7/2-7/9/23; - a Minimum Data Set (MDS, assessment tool) dated 6/20/23, indicated Resident 1 was cognitively intact; it was very important for Resident 1 to choose between a tub bath, shower, bed bath or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.